Provider Demographics
NPI:1629394259
Name:CASEY, TRACY ANNE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANNE
Last Name:CASEY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117B N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3928
Mailing Address - Country:US
Mailing Address - Phone:601-798-6900
Mailing Address - Fax:601-798-6975
Practice Address - Street 1:117B N MAIN ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3928
Practice Address - Country:US
Practice Address - Phone:601-798-6900
Practice Address - Fax:601-798-6975
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3532235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02674391Medicaid